Yellowstone County 2014-2017 - Community Health Improvement Plan - Healthy by ...
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June 30, 2014
Yellowstone County
Community Health Improvement Plan
2014-2017
Sponsored by the Alliance-Billings Clinic, RiverStone Health and St. Vincent Healthcare
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June 30, 2014
Table of Contents
Introduction and Background pg. 3
Community Health Improvement Process pg. 5
Yellowstone County Goals, Objectives and Strategies pg. 12
Appendices pg. 27
Appendix A, CHIP process notes and timeline pg. 28
Appendix B, previous CHIP progress report pg. 35
Appendix C, models impacting the CHNA and CHIP pg. 41
Abbreviation and Terminology Glossary
ACHI: Association of Community Health Improvement
Alliance: institutional leaders of Billings Clinic, RiverStone Health & St. Vincent
Healthcare
CHNA: Community Health Needs Assessment
CHIP: Community Health Improvement Plan
CHIC: Community Health Improvement Coordinator
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June 30, 2014
INTRODUCTION and BACKGROUND
What is a Community Health Improvement Plan (CHIP)?
A Community Health Improvement Plan (CHIP) is a document that presents a long-term systematic
plan to address the health problems of a community. A CHIP is based on the results of a
Community Health Needs Assessment (CHNA) and a community health improvement process.
Creating a successful CHIP involves participation across multiple sectors of a community and it is
supplemented by community member input in addition to public health and health system partners.
The outcome is a defined process through which priorities are selected, and strategies and
measures are created in order to address the health issues identified.
The Community Health Improvement Plan for Yellowstone County
The original CHIP for Yellowstone County was created in 2006 to provide a framework for
increasing the health of residents in Yellowstone County. In addition to providing an action-oriented
plan for the community, the CHIP also presented a summary of the results of the 2005 Yellowstone
CHNA and the process for identifying the priority health issues. The original document was
created to identify and list initiatives aimed toward promoting the healthy weight of Yellowstone
County residents. The document was updated in 2012 following the completion of the 2010-11
CHNA and with a broader scope, addressing health-related issues beyond healthy weight. The
most recent Community Health Improvement Plan has been authored in response to the 2013-14
CHNA results and a structured community process that allowed for the identification of the
priorities. We anticipate this CHIP will be reviewed annually and updated as needed and will be
reframed upon the completion of the next CHNA.
Community Health Needs Assessments
In 2005, RiverStone Health and its system partners underwent an assessment of the public health
system’s performance in the 10 Essential Public Health Services established by the Centers for
Disease Control and Prevention (CDC). The assessment was conducted using the National Public
Health Performance Standards Program (NPHPSP), also established by the CDC. A key outcome
of that assessment was an understanding of the need to perform a CHNA and develop a CHIP.
In 2005, the Alliance of Billings Clinic, Yellowstone City County Health Department dba RiverStone
Health, and St. Vincent Healthcare sponsored the first comprehensive Yellowstone County CHNA
as a follow-up to the NPHPSP assessment. The Alliance contracted Professional Research
Consultants, Inc. (PRC) to perform the assessment which included focus groups with community
leaders and surveys of 400 community members using the random-digit-dialing method. Additional
information on methodology is described in Step 3 of the CHIP process below. This process was
repeated in both 2010-11, and 2013-14 when CHNAs were once again conducted utilizing the
same methodology. The results of the 2005-06, 2010-11 and 2013-14 CHNA can be accessed at
www.healthybydesignyellowstone.org.
Demographics
As the largest city in a 500 mile radius, Billings serves as a commercial and transportation hub for
the state, as well as a major center for education and medical services. Billings benefits from
having a diversified economy, where oil and gas, healthcare, livestock, and banking play significant
roles. The city boasts three colleges (MSU-Billings, MSU-B College of Technology, and Rocky
Mountain College), two major hospitals, two oil refineries, and an international airport.
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Covering 2,633 square miles with an estimated population of 151,882 residents in 2012,
Yellowstone County is the only county which is not designated as “rural.” Billings, the county seat,
is the state’s largest city, with a 2012 population estimated at 106,954. Other cities and towns in
Yellowstone County include: Acton, Ballantine, Broadview, Custer, Huntley, Laurel, Pompey’s
Pillar, Shepherd, and Worden.
The unemployment rate for Yellowstone County as of November 2013 is 3.6% compared to a
statewide rate of 5%. Persons below the poverty level in Yellowstone County (per 2008-2012
data) stand at 11.9% compared with 14.8% statewide.
Montana’s largest minority population is American Indian, at 6.3% of the state’s population
compared to 0.9% nationally. In Yellowstone County, American Indians make up 4.3 percent of the
population, with slightly more Hispanic people at 4.9 percent. The U.S. Census Bureau projects
that by 2025, Montana will have the third highest percentage of elderly in the nation, with nearly a
fifth of its population estimated to be over the age of 65. 2012 Census estimates indicate 15.7% of
Montanans are 65 or older and 14.7% of Yellowstone County residents are 65 and older. By
contrast, persons under 18 stand at 22.1% and 23.5% respectively. The population in Yellowstone
County increased by 2.6% from April 1, 2010 to July 1, 2012 compared with a statewide population
increase of 1.6%.
As described in the 2012 State Public Health Assessment Montana’s population is hovering around
1 million people in an area of nearly 146,000 square miles. In this wide open space, there are only
seven cities with more than 20,000 residents and 15 communities with 5,000 to 19,999 residents.
Nearly all the state’s communities and counties in Montana are designated as Health Professional
Shortage Areas (HPSAs) with Medically Underserved Populations (MUPs).
Sources: MT Dept. of Labor and Industry, US Census Bureau, Montana Department of Public Health and Human
Services, Public Health and Safety Division, 2012 State Public Health Assessment
The Alliance
Yellowstone County is home to Billings, the most populous city in Montana. In addition to being an
economic center, Billings is also a medical hub for the region with three primary health
organizations: Billings Clinic, Yellowstone City County Health Department dba RiverStone Health,
and St. Vincent Healthcare. The Alliance is an affiliated partnership consisting of the Chief
Executive Officers from these three health organizations. The Alliance works collaboratively on
community and regional health initiatives with the mission of identifying community health needs
and then defining and implementing efficient and effective community solutions through integrated
actions. Their vision states, “Together we improve the health of our community, especially those
who are underserved and most vulnerable, in ways that surpass our individual capacity.”
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YELLOWSTONE COUNTY COMMUNITY HEALTH IMPROVEMENT PROCESS
The framework utilized for the 2013-14 health improvement process was the Core Process Steps
from the Association for Community Health Improvement (ACHI). This framework, which is covered
in more detail throughout the next section, contains six generalized steps which were adapted to fit
the needs of Yellowstone County. We have chosen to modify this model by including one
additional step to “complete the circle” and acknowledge the need to revisit and refine. The steps
are shown in the image below. Source: http://www.assesstoolkit.org/assesstoolkit/ACHI-CHAT-
intro-slides-8-27-10.pdf.
Added: 7
Report; revisit and
refine plan and
process. (Step 7)
Additional detail on the steps, including a timeline graphic, is included in the CHIP process outline
in the appendices.
Step One: Establishing the Assessment Infrastructure
The first step in the ACHI framework is to establish the assessment infrastructure. This was completed
by a review of previous processes by the Alliance (leadership representation of Billings Clinic,
RiverStone Health and St. Vincent Healthcare) and identification of key community members to serve
as the CHNA Advisory Group. The Advisory Group was then called upon to assist in finalization of the
assessment make-up and content.
Step Two: Defining the Purpose and Scope
The Scope: The Advisory Group chose to utilize the same scope as the 2005-06 and 2010-
11CHNA by defining the target population as Yellowstone County, hence utilizing geographical
area as the primary identifier.
The Purpose: The determined purpose of the CHNA was to identify key unmet health needs. The
CHNA served as a tool to enhance Yellowstone County’s ability to address three core objectives:
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to improve residents’ health status, increase their life spans, and elevate their overall quality of life;
to reduce health disparities among residents; and to increase accessibility to preventative services
for all community residents.
Step Three: Collecting and Analyzing the Data
Survey Format: PRC utilized a survey instrument customized for Yellowstone County, based the
CDC Behavioral Risk Factor Surveillance System (BRFSS), as well as various other public health
surveys and customized questions addressing gaps in indicator data relative to health promotion,
disease prevention, and other recognized health issues. To ensure the best representation of the
population served, a telephone interview methodology was employed. The primary advantages of
telephone interviewing are timeliness, efficiency, and random-selection capabilities.
The sample design used for this effort consisted of a random sample of 400 individuals aged 18
and older in Yellowstone County. For statistical purposes, the maximum rate of error associated
with a sample size of 400 respondents is ± 4.9% at the 95 percent level of confidence. In addition
to using proven telephone methodology and random-sampling techniques, the raw data was
“weighted” to improve this representativeness even further. Once the raw data was gathered,
respondents are examined by key demographic characteristics (namely gender, age, race,
ethnicity and poverty status) and a statistical application package applied weighting variables that
produced a sample which more closely matches the population for these characteristics.
The sample design and the quality control procedures used in the data collection ensure that the
sample is representative. Thus, the findings may be generalized to the total population of
community members in the defined area with a high degree of confidence.
The CHNA consisted of both quantitative data from primary research and secondary research, as
well as qualitative data (demonstrated in the figure below). The quantitative data was collected
through informant focus groups. The data will serve to study the objectives identified previously.
Customized Local
Community Health Survey
Community Health Needs Assessment
Secondary Focus
Data Groups
The Focus Groups: As part of the CHNA, five community focus groups were held in Yellowstone
County to engage both providers and recipients of various community services. The focus groups
included discussions with key informants in the following areas: medical and other public health
personnel, legislators, employers and employees, educators, social service providers, and a south-
side resident group.
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Potential participants for the focus groups were selected and invited because of their ability to
identify various concerns within Yellowstone County. Providers as well as recipients were engaged
in discussions which focused on recognizing unmet health issues which adversely affect residents
of Yellowstone County, particularly those in underserved populations, including but not limited to
minorities and members of low-income households. A total of 62 individuals participated.
CHNA Benchmarks: Trending –similar surveys was administered in Yellowstone County in 2005-
06 and 2010-11 by PRC on behalf of the Alliance. Trending data, as revealed by comparison to
prior survey results, were provided in the CHNA where available.
Montana Risk Factor Data and Youth Risk Data – Statewide risk factor data were provided where
available as an additional benchmark which to compare local survey findings. State-level vital
statistics were also provided for comparison of secondary data indicators.
Nationwide Risk Factor Data – Nationwide risk factor data were provided where available as an
additional benchmark and were taken from the 2008 PRC National Health Survey.
Healthy People 2010 – This is part of the Healthy People 2010 (HP 2010) initiative, sponsored by
the U.S. Department of Health and Human Services. NOTE: Healthy People 2020 goals were not
available at the time of this survey although they were utilized in the community goal setting.
Secondary Data: Public Health, Vital Statistics & Other Data: A variety of existing (secondary)
data sources was consulted to complement the research quality of the Community Health Needs
Assessment. Data for Yellowstone County were obtained from the following sources:
Centers for Disease Control & Prevention
US Census Bureau
Montana Board of Crime Control
Montana Department of Public Health and Human Services
National Center for Health Statistics
US Department of Health and Human Services
US Department of Justice, Federal Bureau of Investigation
All results were reviewed by an internal workgroup, the Alliance, the CHNA Advisory Group, and
the Healthy By Design Coalition and then released to the public via a press conference and the
website, www.healthybydesignyellowstone.org on 1/21/14.
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Step Four: Selecting Priorities
In the CHNA results, a listing of “Areas of Opportunity” were identified based on the compiled data
including input from the focus groups, results of the phone survey and the secondary data. This
list is offered below.
► Access to Health Services
► Cancer
► Chronic Kidney Disease
► Dementias, Including Alzheimer’s disease
► Heart Disease & Stroke
► Injury & Violence
► Infant Health & Family Planning
► Mental Health & Mental Disorders
► Nutrition, Physical Activity & Weight
► Respiratory Diseases
► Substance Abuse
► Tobacco Use
Decision Process: Following the public release of the CHNA results, a community-wide forum
was convened to garner input from the community on health improvement priorities and
interventions. At the community meeting, with 85 people in attendance, the CHNA results were
shared and community members provided their feedback via a formal individual and group voting
exercise followed by group discussions. The Community Health Improvement Coordinator,
brought on staff at RiverStone Health to work on behalf of the Alliance and Healthy By Design, was
responsible for facilitating this work and the additional steps in the framework.
Criteria used in this process included:
1. Cost and Return on Investment
2. Availability of solutions
3. Impact of problem
4. Availability of resources (staff, time, money, equipment) to solve problem
5. Urgency of solving problem (air pollution, H1N1)
6. Size of problem (number of individuals affected)
Public Health Foundation criteria commonly used to identify priority problems as identified by the National Association of
County and City Health Officials, http://www.phf.org/infrasturcture/priority-matrix.pdf, accessed 2/9/10.
The CHNA Advisory Committee was reconvened after the forum to validate the priority ranking
process and results and to review the community’s input. Much of the strategy development began
to take shape during these meetings. Goals, objectives, and measurable outcomes were drafted,
by the workgroup based on the results of the Community Forum and input from the Advisory
Committee. Once the goals and objectives were drafted, expert meetings were held, which called
upon community experts in each of the identified priority areas. The feedback from these experts
then helped to shape the final draft of the goals and objectives, as well as give input into the
strategies.
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Creation of Goals and Objectives - Assets: During the goals and objectives creation, it was
important to acknowledge the assets available to the community. The first asset identified was the
Alliance itself. The Alliance brings together two healthcare organizations and the local health
department to collectively work on community health issues. This asset is arguably the strongest
asset identified during the development of the CHIP as this partnership allows for the following:
The pooling of information
Increased amount of available resources, human and financial
Better understanding of community needs and assets
Engagement in new issues without having sole responsibility or management of them
Development of widespread public support for issues
Minimal duplication of services and effort
An additional asset is the pre-existing Healthy By Design Initiative. The Healthy By Design Initiative
began in 2005 following the first CHNA. The initiative was designed to work on physical activity
and nutrition policy, systems, and environmental changes in Yellowstone County. The mission of
Healthy By Design is to create a community that is healthy by design, (i.e. to intentionally influence
the environment in which people live, learn, work and play) so that positive health effects are
enhanced and negative health effects are mitigated). Creation of the Healthy By Design Coalition
brought together a valuable network of human assets including professionals with expertise in
health, infrastructure, engineering and planning; the largest medical center in a 500-mile radius;
and a strong network of non-profits and community action groups. Healthy By Design has a
proven track record of successful collaboration and is well known and respected in the community.
Going forward, the framework of Healthy By Design will be utilized to engage the community in the
chosen community priority areas.
These and additional assets are named under each identified priority below, with the
understanding that this is not a comprehensive list. The Community Health Needs Assessment
also contains an organizational listing that will be referenced at the workgroup level.
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Community Priorities
Following CHNA opportunity identification, Community Forum voting, and CHNA Advisory
Committee validation, three areas were identified as the priority community health needs:
a. Healthy Weight
b. Access to Health Services
c. Mental Health, Mental Disorders and Substance Abuse
Key CHNA results related to these three health issues are presented below in the goals, objectives
and strategies section.
Step Five: Documenting and Communicating Results
After the community goals were constructed, the next step of the ACHI six-step framework is
communication of results. This step, in the context of Yellowstone County, began simultaneously
with steps three and four. This step included
announcing the results of the Community Health
Needs Assessment to key stakeholders, media and
public followed by collection and communication of
feedback from the community forum and expert
meetings. By inviting the community to the forum and
involving community experts in discussions we were
ensured that the voice of the community would be
incorporated in the construction of the CHIP. As
strategies emerge, updates of work plans will
continue to be communicated with the stakeholders
and the community. This will be facilitated through
Coalition meetings, posting on the Healthy By
Design website www.healthbydesignyellowstone.org,
and through social media on the Healthy By Design
Facebook page. In order to assist in documentation
of process, an appendix with notes on the steps
taken throughout the CHNA/CHIP formation is
included.
Achieving the Goals
The role of the health organizations and community connection
The involvement of key community members and organizations is vital to achieving the goals set
forth in the CHIP. To ensure success, the Alliance has taken on the role of the community
facilitator and will dedicate the needed resources to provide this facilitation.
Access to Health services and Mental Health, Mental Disorders and Substance Abuse: Though
mental health and access to health services were identified in the previous CHIP, work
accomplished was minimal. Therefore, the work completed on these goals during the next three
years will focus on building foundations for the work through the identification of partners,
identification of policy changes required to achieve the objectives, determining future action steps
required to be successful. The successful model of community engagement provided by Healthy
By Design will serve as a model for establishing community involvement, as well as the facilitation
of community discussion and initiatives aimed at increasing access to health services and
improving mental health and substance abuse outcomes for Yellowstone County residents.
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Healthy Weight: The work on healthy weight will be conducted by Healthy By Design; a pre-
existing coalition created by the Alliance to focus on creating a community that is healthy by design
(to intentionally influence the community in which we live to make the healthy choice the easy
choice). More information on Healthy By Design, including recent work plans, is available on the
Healthy By Design website www.healthybydesignyellowstone.org.
Step 6: Planning for Action and Monitoring Progress
Follow-up is an essential part of ensuring that goals and objectives are met. Annual work plans will
be created to ensure that a plan exists detailing the activities required to achieve objectives, the
person(s) responsible for the activities, and the timeline for completion. Annual creation of the
work plan will be conducted by January 1st of each year and it is the responsibility of the Alliance.
The status of the work will be reviewed semi-annually at the Alliance meeting.
The CHIP will be publically accessible on all Alliance organization websites and on the Healthy By
Design website: www.healthybydesignyellowstone.org. In addition, the Community Health
Improvement Coordinator, in partnership with the Alliance Communication Team, will be
responsible for ensuring periodic status updates through media channels, social media, and semi-
annual reports. The CHIP will be reviewed annually and updated as needed and following the
completion of the Yellowstone County CHNA (the next one is scheduled for 2017).
Additional Step 7: Report, revisit and refine plan and process
This step has been added to the ACHI framework in order to remind us that this is a “living
document” that needs to be reviewed and refined as needed in order to accommodate discoveries,
changes and accomplishments. We also expect that this document and the accompanying work
plans will inform our next CHNA and CHIP.
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Yellowstone County Goals, Objectives and Strategies
Goals and Objectives approved by the Alliance of Billings Clinic, RiverStone Health and St. Vincent
Healthcare on June 4, 2014, with additional Alliance partner and community expert discussion on
strategies following
Contributors: Community Health Needs Assessment Workgroup, Community Health Needs
Assessment Advisory Group, Community Forum Participants, Content Area Expert Meeting
Participants and the Alliance Members
Overarching Goals
In response to the state of Montana’s Plan to Improve the Health of Montanans’ (June 2013)
challenge to strengthen the public health and healthcare system, and its proposed system
improvement goals, we offer the following overarching goals that we believe apply to our identified
priorities and our work in Yellowstone County. Through the Alliance, existing coalitions, and future
collaborative work involving sectors of the community impacting the social correlates of health (see
diagram below), we will:
strengthen partnerships and formulate effective community responses to make lasting
and measurable change;
promote effective public health policies and adequate public health funding; and
promote the use of evidence-based interventions and practice guidelines.
Methodology
Each SMART objective target listed in the Community Health Improvement Plan is based on the
Healthy People 2020 standard target of 10 percent change (%change = [(2nd year value-1st year
value)/1st year value) x 100] unless noted otherwise. Baseline is taken from the 2014 Community
Health Needs Assessment (which also includes secondary sources) unless otherwise noted.
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PRIORITY AREA: Nutrition, Physical Activity and Weight
In the area of improving healthy weight status we have interfaced with and identified the following
collaborators/resources: Healthy By Design Coalition and Workgroups, School Health Advisory
Council, Billings Action for Healthy Kids, Big Sky Economic Development, Bike/Ped Advocate. We
anticipate engaging additional parties.
The problem: Because weight is influenced by energy (calories) consumed and expended
interventions to improve diet and physical activity can support changes in weight. They can help
change individuals’ knowledge and skills, reduce exposure to foods low in nutritional value and
high in calories, or increase opportunities for physical activity. Interventions can help prevent
unhealthy weight gain or facilitate weight loss among obese people. They can be delivered in
multiple settings, including healthcare settings, worksites, or schools. The social and physical
factors affecting diet and physical activity may also have an impact on weight. Obesity is a problem
throughout the population. However, among adults, the prevalence is highest for middle-aged
people and for non-Hispanic black and Mexican American women. Among children and
adolescents, the prevalence of obesity is highest among older and Mexican American children and
non-Hispanic black girls. The association of income with obesity varies by age, gender, and
race/ethnicity. -Healthy People 2020, www.healthypeople.gov **
CHNA Findings: The key areas of concern noted in the 2014 Community Health Needs
Assessment include: overweight/obesity prevalence and physical activity levels. Additional
concerns were noted during the Community Health Forum held in February 2014 as part of the
priority setting process. These include: a desire to focus on children and address modifiable
behaviors and food security issues.
Yellowstone County residents less likely to meet physical activity requirements include: women,
seniors (65+) and residents in low-income households.
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Yellowstone County’s findings are similar to statewide (24.4%) and national findings (20.7%) and
meet the Healthy People 2020 target of 32.6% or lower.
Yellowstone County’s rate is similar to the national rate of 39.5% and has not changed significantly
since 2005.
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Though a difference is noted, it is not statistically significant. The findings are comparable to
national rates.
**Additional Healthy People 2020 information available in the Community Health Needs
Assessment and on the Healthy People 2020 website
THE GOAL: Improve Healthy Weight Status
Healthy Weight Status Health Objectives:
1) By 2017, the proportion of adults in Yellowstone County who have a healthy weight
(Normal BMI range: 18.5-24.9) will increase from 31.9% to 35%. (HP NWS-8) (9.7%
change; 35.8% reported in 2005 CHNA 2014)
2) By 2017, the proportion of adults in Yellowstone County reporting no leisure-time
physical activity in past month will decrease from 23.7% to 21.25%. (10.34% change;
HP PA-1; leisure-time can be discussed publicly as “every day” activity
3) By 2017, the proportion of adults in Yellowstone County who eat 5 or more servings
of fruit and vegetables per day will increase from 40% to 44%. (10% change; Related:
HP NWS-14 and HP NWS-15.1 LHI)
4) By 2017, the proportion of children in Yellowstone County who are physically active
for one or more hours per day (ages 2-17) will increase from 42.8% to 47% (9.8%
change; CHNA- “each of seven days preceding the interview”; Related to HP PA-3.1-“meet
current physical activity guidelines for aerobic physical activity”)
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Overarching Strategies:
Public Health Policy
Encourage workplaces adopting Healthy By Design nutrition and physical activity guidelines
and developing worksite wellness policies and healthy work environments
Support Yellowstone County area school-based efforts to increase students’ daily
consumption of fruits and vegetables and increase student’s physical activity levels
Prevention and Health Promotion Efforts
Promote the use of the 5-2-1-0 awareness campaign
Encourage organizations to apply for Healthy By Design recognition
Encourage awareness of and response to gender-based physical activity disparities
including increasing awareness regarding incorporation and recognition of physical activity
in everyday activity
Promote the use of active transportation where available
Support the valuation of built environment as it relates to health and safety
Access to Care, Particularly Clinical Preventive Services
Incorporate consistent recording of BMI and healthy weight discussions in Alliance partner
electronic medical records
Yellowstone County’s Public Health and Healthcare System
Advocate access to healthy foods for low-income individuals and families (i.e. WIC, SNAP,
food pantries, school-based approaches, etc.) (supported by The National Prevention
Strategy)
Tactics will be developed at a work group level, executed and reported via developed work plans
and will respond to the identified strategies, positively impacting the identified objectives and goals.
Progress will be recorded and reported semi-annually to the Alliance.
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PRIORITYAREA: Access to Health Services
In the area of access to health services we have interfaced with and identified the following
collaborators/resources: United Way of Yellowstone County and Best Beginnings Council, and
legislators. We anticipate engaging additional parties.
Problem: Access to comprehensive, quality health services is important for the achievement of
health equity and for increasing the quality of a healthy life for everyone. Access to health services
impacts: overall physical, social, and mental health status; prevention of disease and disability;
detection and treatment of health conditions; quality of life; preventable death; and life expectancy.
Access to health services allows the timely use of personal health services to achieve the best
health outcomes. Three distinct steps are required to achieve access: 1) Gaining entry into the
healthcare system. 2) Accessing a healthcare location where needed services are provided. 3)
Finding a healthcare provider with whom the patient can communicate and trust. -Healthy People
2020, www.healthypeople.gov
CHNA Findings: The key areas of concern noted in the 2014 Community Health Needs
Assessment include: lack of healthcare coverage for ages 18-64 years, barriers to accessing
healthcare services, and access to dental care, especially for low-income households. Additional
concerns were noted during the Community Health Forum held in February 2014 as part of the
priority setting process. These include: jointly addressing access-related policy issues, promoting
primary care and offering or identifying points-of-entry into care and healthcare navigation.
Adults under the age of 65 are less likely to have a specific source of care, at a rate of 78.2% for Yellowstone
County residents age 18-64.
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The lowest utilizers are those who do not have dental insurance and those in low income households.
Among Yellowstone County adults, rates of uninsured are lower than Montana’s rate (24.1%
uninsured) and slightly higher than the US rate (15.1%). The findings for Yellowstone County are
statistically similar to the 2005 findings.
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2013-14 findings are lower than national findings (8.9%) and statistically similar to the 2005
findings. There is no statistical difference in ER use when viewed by demographic characteristics.
**Additional Healthy People 2020 information available in the Community Health Needs
Assessment and on the Healthy People 2020 website
THE GOAL: Improve Access to Health Services
Access to Care Objectives:
1) By 2017, the proportion of adults in Yellowstone County who have a specific source
of ongoing care will increase from 81.7% to 85%. (HP AHS-5) (4.03% change);
Question: Is there a particular place that you usually go if you are sick or need advice about
your health? If Yes, what kind of place is it: A Hospital-Based Clinic, A Clinic That is NOT
Part of a Hospital, An Urgent Care/Walk-In Clinic, A Doctor's Office, A Hospital Emergency
Room, Military or Other VA Healthcare, or Some Other Place. For the next assessment, we
will be redefining “on-going care”.
2) By 2017, the proportion of adults in Yellowstone County who have visited a dentist or
dental clinic in the past year will increase from 62.9% to 69% (HP AHS 6.3) (9.69%
change; addressing key area of concern)
3) By 2017, the proportion of adults in Yellowstone County who are without health
insurance will decrease from 16.7% to 15% (HP AHS 1.1; 10.18% change; addressing
key area of concern)
4) By 2017, decrease proportion of adults in Yellowstone County who have used the ED
more than once in past year from 5.8% to 5.2%. (10.34% change; CHNA 2014: 5.8%,
7.8% among low income households; 8.6% in CHNA ‘10)
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Access to Health Services Overarching Strategies:
Public Health Policy
Advocate for Medicaid Expansion
Advocate for access to healthcare and dental service programs that assist those with financial
need (e.g. Medicaid, Healthy Montana Kids, Medication Assistance Program, Community
Health Access Partnership) through the development and advocacy of an Alliance legislative
agenda
Prevention and Health Promotion Efforts
Develop a collaborative strategy to educate residents of Yellowstone County about what health
insurance means and how to use it effectively (continuum of “covered to care”)
Access to Care, Particularly Clinical Preventive Services
Explore avenues of asset mapping along the continuum of care that provides residents of
Yellowstone County access to resources and services.
Encourage patient centeredness when making decisions related to location and hours of
services.
Yellowstone County’s Public Health and Healthcare System
Promote the Montana Family Medicine Residency, Internal Medicine Residency and Dental
Residency programs and consider the development of other residencies that may offer
pathways to appropriate workforce development
Promote health insurance acquisition via the Health Insurance Marketplace or other avenues at
each Alliance institution.
Examine emergency department utilization across organizations and respond accordingly.
Develop recommendations as appropriate. Identify high users and strategies to increase health
outcomes and reduce costs.
Support full implementation and evaluation of the Patient Centered Medical Home model in
each Alliance member institution.
Tactics will be developed at a work group level, executed and reported via developed work plans
and will respond to the identified strategies, positively impacting the identified objectives and goals.
Progress will be recorded and reported semi-annually to the Alliance.
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PRIORITY AREAS: Mental Health & Mental Disorders and
Substance Abuse
In the areas of mental health and substance abuse we have interfaced with and identified the
following collaborators/resources: Chronic Pain Task Force, Substance Abuse Prevention
Partnership [via United Way], Best Beginnings, Mental Health Center, Crisis Center, Rimrock
Foundation and Suicide Prevention Coalition of Yellowstone Valley. Let’s Talk Billings, and
reformation of the Tobacco Free Coalition. We anticipate engaging additional parties.
Problem: Mental Health plays a major role in people’s ability to maintain good physical health.
Mental illnesses, such as depression and anxiety, affect people’s ability to participate in health-
promoting behaviors. In turn, problems with physical health, such as chronic diseases, can have a
serious impact on mental health and decrease a person’s ability to participate in treatment and
recovery. Mental health is essential to personal well-being, family and interpersonal relationships,
and the ability to contribute to community or society. Mental disorders contribute to a host of
problems that may include disability, pain, or death. The resulting disease burden of mental illness
is among the greatest of all diseases with an estimated 13 million American adults (approximately
1 in 17) having a seriously debilitating mental illness. The leading cause of disability in the United
States and Canada, mental illness accounts for 25 percent of years of life lost to disability and
premature mortality. Moreover, suicide is the 11th leading cause of death in the United States,
accounting for the deaths of approximately 30,000 Americans each year. Additionally, most recent
reports indicate Montana and Wyoming are tied for first in the nation for the number of suicides.
Mental health and physical health are closely connected. -Healthy People 2020,
www.healthypeople.gov ** and additional public health sources
CHNA Findings: Mental Health: The key areas of concern noted in the 2014 Community Health
Needs Assessment include: suicides, access to mental health treatment and resources for mental
health treatment. Additional concerns were noted during the Community Health Forum held in
February 2014 as part of the priority setting process. These include: coordination of services, lack
of services, developing common strategies, communication, access, stigma associated with mental
health problems, and youth resources.
21June 30, 2014
A total of 62.5 % of Yellowstone County adults rate their overall mental health as “excellent” or
“very good”. With a rate of 10.6%, Yellowstone County reported similar “fair/poor” responses to
national ratings.
A total of 9.7% of Yellowstone County residents have considered suicide at some point in their
lives. The county suicide rate has fluctuated over time, showing no clear trend. Across Montana
and the US overall, suicide rates have increased over time.
______________________________________________________________________________
22June 30, 2014
Problem: Substances: Social attitudes and political and legal responses to the consumption of
alcohol and illicit drugs make substance abuse one of the most complex public health issues. In
addition to the considerable health implications, substance abuse has been a flash-point in the
criminal justice system and a major focal point in discussions about social values; people argue
over whether substance abuse is a disease with genetic and biological foundations or a matter of
personal choice. In 2005, an estimated 22 million Americans struggled with a drug or alcohol use
problem. Almost 95 percent of people with substance use issues are unaware of their problem. Of
those who do recognize their issues, 273,000 have made an unsuccessful effort to obtain
treatment. These estimates highlight the importance of increasing prevention efforts and improving
access to treatment for substance abuse and co-occurring disorders. Substance abuse has a
major impact on individuals, families, and communities. The effects of substance abuse are
cumulative, significantly contributing to costly social, physical, mental, and public health problems. -
Healthy People 2020, www.healthypeople.gov **
Substance Abuse: The key areas of concern noted in the 2014 Community Health Needs
Assessment include: Cirrhosis/liver disease deaths, chronic alcohol use, drug-related deaths, and
availability of substance abuse treatment. Noted during the Community Health Forum held in
February 2014 was untreated patient populations and their interactions; need for preventive
measure reimbursement, need to increase addiction prevention education in schools, need to
educate on the environmental impact caused by those who are addicted, and consideration of
policy work around Driving Under the Influence (DUIs).
A significant increase in chronic drinking is denoted from 2005-06 and 2010-11 to 2013-14.
Chronic drinking is more prevalent among men (10.2%) in Yellowstone County.
______________________________________________________________________________
23June 30, 2014
Problem: Tobacco use is the single most preventable cause of death and disease in the United
States. Each year, approximately 443,000 Americans die from tobacco-related illnesses, like
cancer and heart disease. For every person who dies from tobacco use, 20 more people suffer
with at least 1 serious tobacco-related illness. In addition, tobacco use costs the U.S. $193 billion
annually in direct medical expenses and lost productivity. There is no risk-free level of exposure to
secondhand smoke. Secondhand smoke causes heart disease, emphysema, and lung cancer in
adults and a number of health problems in infants and children, including: severe asthma attacks,
respiratory infections, ear infections, and sudden infant death syndrome (SIDS). Smokeless
tobacco causes serious oral health problems, including cancer of the mouth and gums,
periodontitis, and tooth loss. Cigar use causes cancer of the larynx, mouth, esophagus, and lung. -
Healthy People 2020, www.healthypeople.gov ** and additional public health sources
Tobacco Use: The key area of concern noted in the 2014 Community Health Needs Assessment
focused on smokeless tobacco. This was not identified as one of the top areas of concern at the
Community Health Forum.
The current smoking percentage has decreased significantly since 2005-06. Smoking rates do not
vary significantly by demographic characteristics.
**Additional Healthy People 2020 information available in the Community Health Needs
Assessment and on the Healthy People 2020 website
24June 30, 2014
THE GOAL: Improve Mental Health and Reduce Substance Abuse
Mental Health Objectives:
1) By 2017, the proportion of adults in Yellowstone County who report their mental
health as being good, very good, or excellent in the past 30 days will increase from
89.4% to 94%. (6.2% change-slightly over 2011 rate; 2011 BRFSS county baseline: “14
plus days in past 30 of ‘not good’ mental health” 10.8%; defined in BRFSS question as
“stress, depression and other problems with emotions”; relates loosely to HP MHMD 4
“persons who experience MDE”; 2014 CHNA “overall mental health fair or poor”-10.6%)
2) By 2017, the reported suicide rate in Yellowstone County will be reduced from 17.3
deaths per 100,000 to 16.3 per 100,000 population. (HP MHMD-1 LHI; 5.7% change from
2008-10 rates; aligns with 2007-09 rates)
Substance Objectives:
1) By 2017, reduce the proportion of adults in Yellowstone County who report drinking
chronically from 7.1% to 6.4%.(9.86% change; no chronic drinking HP 2020 or SHIP
indicator; BRFSS: “Heavy Drinking” more than 2 per day-men; more than 1 per day-women:
4.9% in 2012; significant increase in 2014 CHNA; “chronic” defined as 60 or more drinks of
alcohol in the month preceding)
2) By 2017, pursue at least one policy focused opportunity related to chronic pain and
opioid abuse that will positively impact the residents of Yellowstone County. (related
to HP SA-19; measure: execution of steps of policy campaign)
Tobacco Objectives:
1) By 2017, reduce the proportion of adults in Yellowstone County who report smoking
cigarettes from 11.7% to 10.5%. (10.26% change; HP TU 1.1 LHI)
2) By 2017, pursue at least one policy focused opportunity related to smoke
free/tobacco free facilities, campuses, worksites, or public spaces (e.g. parks,
housing) that will positively impact the residents of Yellowstone County. (HP TU-15;
measure: execution of steps of policy campaign)
Mental Health & Mental Disorders, Substance Abuse (including Tobacco) Overarching Strategies:
Public Health Policy
Establish a county baseline and create community guidelines for prescribing controlled
substances and discouraging nonmedical use of pain relievers in Yellowstone County. (HP
19.1; SAMHSA DSDUH report, 1/8/13 MT-4.83%; 4.6% nationally, with a range of 3.6-6.4%)
Promote and encourage policy opportunities related to smoke free/tobacco free facilities,
campuses, worksites, or public spaces (e.g. parks, housing) (HP TU-15)
Support advocacy efforts to reduce gaps in prevention, as well as support treatment for co-
occurring disorders and treatment of family units
Prevention and Health Promotion Efforts
Increase capacity for trauma-informed care education, promotion, collaboration and
implementation
Support suicide prevention by increasing the number of people in the community who have
received suicide prevention training.
25June 30, 2014
Access to Care, Particularly Clinical Preventive Services
Continue to support the Community Crisis Center
Increase access to behavioral health specialists in primary care settings
Explore avenues of asset mapping to provide residents of Yellowstone County access to
resources and services.
Continue promoting depression screening and referral for adolescents over the age of 12 as
well as adults (Increase depression screening HP MHMD 11)
Yellowstone County’s Public Health and Healthcare System
Identify, support, convene, and/or engage in community-collaborative work focused on the area
of mental health in order to address communication and treatment gaps. (Measure:
membership and a related developed strategy)
Examine emergency department utilization across organizations. Develop recommendation as
appropriate. Identify high users and strategies to increase health outcomes and reduce costs.
Tactics will be developed at a work group level, executed and reported via developed work plans
and will respond to the identified strategies, positively impacting the identified objectives and goals.
Progress will be recorded and reported semi-annually to the Alliance.
**Additional Healthy People 2020 information available in the Community Health Needs
Assessment and on the Healthy People 2020 website
26June 30, 2014
APPENDICES
27June 30, 2014
Appendix A: CHNA/CHIP process notes and timeline
CHNA/CHIP Process Outline 2013-14
1) Establishing the Assessment Infrastructure
Nov. 12-Jan 13 – Alliance-appointed committee meets to discuss approach to CHNA process. Key
questions include: What should be the scope? Will we do it ourselves or contract the work? Who are the
potential contractors and what value will they bring to the process at what cost? Committee members
included: John Felton, Barbara Schneeman, Hillary Hanson, Carol Beam & Tracy Neary from SVH,
Kristianne Wilson & Jeannie Manske from BC. The result of this series of meetings was a decision to
contract with PRC to complete the assessment in a similar fashion to the assessment completed in 2010.
Minutes may exist from these meetings.
2) Defining the Purpose and Scope
In an effort to gather more community voice in the design of the CHNA process, about 25 community leaders
were invited to be part of the CHNA Advisory Group. The HBD leadership team brainstormed the list of
people to invite. The group met on 3/26 & 4/23 to review the base survey questions and offer
recommendation for additions/deletions as well as recommend focus group participants. The group
recommended including additional secondary data sources, specifically MT Youth Risk Behavior Survey
(YRBS). Additional details of these meetings are available in notes taken by Jeanne Manske, available in
the CHNA files held by the CHIC.
Hillary, Jeannie & Tracy coordinated these meetings and continued to lead follow-up work related to
finalizing questions for the survey. Other HBD leaders, especially April & Laura contributed to this process.
It was also discussed at the quarterly HBD Advisory meeting. Hillary, Jeannie & Tracy signed off on the final
list of survey questions & invitation list for focus group participants. As reviewed by Heather, there is
nothing specific in HBD Coalition minutes. May be a string of e-mail correspondence from Tracy.
3) Collecting and Analyzing the Data
Focus Groups- There were a total of 62 attendees in all five focus groups completed 8/15 & 8/16 (Employers
– 9 attendees, Social Service Providers – 8 attendees, South Side Neighborhood Community Members - 24
attendees, Physicians and Other Health – 16 attendees, Government – 5 attendees). At the end of each
focus group, we have participants list their top health concerns. We have documentation of the individuals
invited to participate and sign in sheets of those actually attending the focus groups. In addition to a
facilitated discussion, groups were asked to share their top five health needs. Documentation of findings will
be included in the report. Additional detail available in CHNA report.
Telephone Survey- began in October to include 400 households in Yellowstone County. Findings will be
included in the final report. Completed in November 2013.
CHNA Report, (We anticipate a formal 200+ page report, summary reports, power point presentations and
access to data files for custom queries) will be provided by PRC first week of December to staff/HBDL. Due
to IRS expectations of tax-exempt hospitals to “conduct” assessments and adopt implementation plans in the
same tax year; results will not be posted on any websites or shared with the media until after Jan 1, 2014.
Internal Analysis
nd
On November 22 the CHNA workgroup (Shawn, Jeanne, Barbara, Tracy and Heather) met to discern
process for previewing report (related to IRS and accreditation standards), analyzing data, previewing with
additional vested groups, public announcement planning and prioritization process.
th
Dec. 8 -a meeting of CHNA workgroup and HBDL to preview report results and to gather initial feedback to
th
PRC in preparation for presentation to the Alliance on Dec. 18 was conducted. CHIC provided assignments
of topic areas to HBDL/CHNA workgroup staff for the Alliance meeting and for review/feedback.
Presentation with Alliance will include a 30-40 minute presentation from PRC, Q&A from Alliance based on
presentation, Overview of current CHIP goals and data summary slide and review of timeline of CHNA. A
28June 30, 2014
selection of several criteria considering for priority selection were also presented (Presentation determined
by CHNA workgroup and CHIC)
Additional feedback from HBDL will be gathered remotely/via email in order to ensure alignment with IRS
and accreditation. Feedback or any revisions will be given to PRC following the Alliance presentation of the
th
CHNA report overview by PRC to the Alliance and compilation of HBDL feedback. (Goal-by Dec. 20 -CHIC)
Regarding CHNA report, additional work is assumed to be occurring at each Alliance organizational level to
review and provide feedback to the whole via their HBDL membership.
Edits were compiled and submitted to PRC on 12-23. A follow-up phone conversation with PRC to clarify
edits occurred on 12-30. Follow-up tasks are being executed by the CHIC. The schedule of edits and final
reports was determined at this time. Edits were collected from HBDL on the Focus Group section until 1/7
and then sent to PRC. The Executive Summary was completed by 1-8 and the final report with edits was
returned on 1-14-14.
Edits to the external website (healthforecast) were drafted by CHIC, reviewed by a HBDL member and sent
to PRC. The HBD website has been prepped for the CHNA report posting and has been updated with an
announcement of the Community Forum. The report and summary were provided to the webmaster in
advance of 1-21.
The CHNA was posted on the Healthy By Design website and the Alliance partner websites on 1/21/14.
4) Selecting Priorities
Process begins with announcement and availability of results and public feedback.
Dec. 19, 2013: follow-up meeting of the CHNA workgroup to solidify logistics of press conference, community
forum and key interest group communication. Finalized logistics via email.
Jan 21st, Breakfast meeting, 7:30 am-9:00, HBD Coalition, 20-40 (guesstimate) (in Mary Alice
Fortin Health Conference Center, rooms B & D, BC) (emailed, with reminder email, to ask to rsvp
BY 1-17)
Jan 21st Preview meeting, 11:00 am, CHNA Advisory Group, Stillwater Room, RSH (Heather
sent letter and follow up email to this group)
Jan 21st, 12:15-12:45 press conference in the Stillwater Room at RSH (Barbara and Heather put
together details)
Feb 4th, 11-1, Community Forum at the Library Community Room (reserved), will include
Coalition plus list emailed, plus public messaging (Heather sent email to HDB Coalition to save
the date, sent emails to key groups and contacts to distribute, asking for an RSVP for light lunch;
will send letters to previous focus group attendees, as emails are unavailable)
Emails and letters for the January 21 meetings were drafted by the CHIC and sent to the CHNA
st
workgroup for review before 1/7. Both were distributed on 1/7, with a follow-up email to HBD
Coalition for breakfast RSVP by 1/17.
Meeting to flesh out agenda for preview meetings occurred 1-17-14 among CHNA workgroup.
Meeting format-slide deck from PRC Alliance presentation was altered only slightly and
presented to both the Coalition and Advisor group. Attendance was captured on a list for the
Coalition and in notes for the Advisory group. Notes of general questions and comments were
recorded. A few comments were collected via notecards from attendees. It is intended that the
Advisory group will be reconvened following the Community Forum to further delve into priorities.
Press conference date, time and location were coordinated by CHIC with input from Alliance org Executive
Assistants and CHNA workgroup. Date and time: January 21, 12:15-12:45. A media advisory and agenda
were drafted by CHIC, with review by RSH Comm. Dir. and approval by the media contacts at both hospitals
via CHNA workgroup representatives as of 1-2-14.
Preview meetings were conducted with the following groups:
29June 30, 2014
Present preview to CHNA Community Advisory Group (phone, email and press conference invite-
early Jan) Group previously (2013-to assist in CHNA development) established. Gather initial
impressions. Invite to community forum.
o Occurred: January 21, 2014
o Feedback was to have a follow-up meeting to further discuss priorities
o Attendance tracked
o Comments collected
o Notes taken
Present preview to HBD Coalition (email and press conference invite-early Jan)
Purpose will be to recognize their commitment to the work conducted to date and acknowledge long journey,
where we have been, data trends and share points that reinforce what we are doing. Any surprises. Gather
their initial impressions. Invite to community forum.
Occurred: January 21, 2014
Comments were collected.
Attendance tracked.
Notes taken
Schedule and Conduct Press Conference announcing high-level results and community meeting
(Community Forum-per CHNA language)
It was determined by the CHNA workgroup that the United Way will be invited to
participate in the press conference. RSH Communications Director communicated
with United Way contact and prepped for conference. Slides were drafted by CHIC,
reviewed with RSH Communications and reviewed by HBDL.
HBDL were tasked with sharing information with their marketing communications
team and getting any feedback back to CHIC. CHIC sent final agenda and slides
CEO’s assistance on 1-17 in advance of the 1-21 press conference.
Schedule and conduct priority identifying meetings with following groups:
o CHNA Community Advisory Group (Jan 21st)
o HBD Coalition/workgroups (Jan 21st)
o Community Forum (Feb 4th)
Attendee invitation list: newspaper business advertisement, newspaper calendar
invitation, previous focus group invitation lists (mail), HBD Coalition, HBD email list,
Facebook, CHNA advisory group, and other outreach to groups including
workgroups, Best Beginnings Council, Center for Children and Families email list,
colleges, RiverStone Health Population Health Staff and Clinic Board, Yellowstone
Valley Suicide Coalition, Family Promise email list, Library Foundation Board, and
others.
Logistics, RiverStone Health heavily supported logistics planning by offering CDC
fellow, Dasheema Jarrett to assist and day of event volunteers. HBD Leadership and
Co-Leaders led discussion groups and assisted with presenting.
Following research by CHIC on prioritization models, and agenda drafting, an
Agenda finalizing meeting occurred with CHNA workgroup on 1/29/14.
Additional informal CHNA results meeting occurred with Big Sky Economic Development with CHIC and
Tracy Neary per their request.
Results were also highlighted during two Channel 7-community station interviews. Announcement of the
upcoming Community Forum was also made.
FORUM AGENDA
11:00 REGISTRATION (10 minutes)
11:10 WELCOME (5 minutes)
11:15 HISTORY/FRAMEWORK (5 minutes)
11:20 RESULTS Community Health Needs Assessment Summary (30 Minutes)
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